Kate Johnson

May 15, 2013

NEW ORLEANS, Louisiana — Obstetricians and gynecologists are better than other physicians at following guidelines for the management of intrauterine devices (IUDs) in patients with sexually transmitted infections (STIs). But they too have a lot to learn, researchers report.

"We found that there are many misconceptions about STI diagnoses and continued IUD use, even among ob/gyns," researcher Catherine Cansino, MD, from the University of California, Davis in Sacramento, told Medscape Medical News.

The study by Dr. Cansino and her team was awarded first prize here at the American Congress of Obstetricians and Gynecologists (ACOG) 61st Annual Clinical Meeting.

"Despite wide distribution of practice guidelines, by both the ACOG and the Centers for Disease Control and Prevention (CDC), physicians are still not very well informed," Dr. Cansino said.

When it comes to chlamydia and pelvic inflammatory disease, both the ACOG and the CDC support nonremoval of an IUD, explained presenter Beth Cottongim, MD, from the Ohio State University Wexner Medical Center in Columbus.

Despite these guidelines, the researchers found that many ob/gyns and even more primary care physicians would elect to remove IUDs in such situations.

Guidelines Say Leave the IUD

The inspiration for the study came from "several patients who were seen in our ob/gyn resident clinic who had had their IUDs removed or were told by a non-ob/gyn physician that their IUDs needed to be removed," said Dr. Cottongim. "All of the women were in situations where we would have chosen not to remove their long-term birth control."

For their observational cross-sectional study, the researchers used a self-administered survey of 87 emergency medicine, family medicine, internal medicine, and ob/gyn physicians at Wexner Medical Center.

The survey provided 10 brief clinical scenarios of patients with current IUDs in place, and asked physicians to say whether the IUD should remain in place or be removed.

For 8 of the scenarios, there was no statistically significant difference among the physicians on the basis of age, level of training, or years in practice.

However, for 2 responses — one related to chlamydia and the other to pelvic inflammatory disease — there were statistically significant differences.

When asked about a patient with an IUD in place and a positive chlamydia test on routine screening, 8% of ob/gyns opted for removal of the IUD, despite ACOG and CDC guidelines to the contrary.

"Non-ob/gyns were even more likely to advocate for the removal of the IUD; there were no difference between the other specialties," said Dr. Cottongim.

For a patient diagnosed with pelvic inflammatory disease with an IUD in place, "the data support conservative management," said Dr. Cottongim. However, 65% of ob/gyns recommended removal.

Table. Recommendation for IUD Removal By Specialty

Specialty Patients With Chlamydia, % Patients With Pelvic Inflammatory Disease, %
Ob/gyn 8 65
Internal medicine 60 93
Family physician 50 100
Emergency medicine 30 93

Physicians who manage IUD patients more frequently were less likely to opt for removal in the case of chlamydia (odds ratio [OR], 0.27; P < .001) and pelvic inflammatory disease (OR, 0.47; P < .01).

"This is not an unexpected result," Dr. Cottongim said. "You would expect physicians who encounter these patients on a more frequent basis to be more familiar with the guidelines advocating conservative treatment."

For example, of physicians who reported managing both scenarios every day, 100% opted for conservative management in the case of chlamydia and 50% opted for it in the case of pelvic inflammatory disease.

In contrast, of physicians who reported managing such cases fewer than 6 times per year, 51.0% opted for conservative management in the case of chlamydia and 5.7% opted for it in the case of pelvic inflammatory disease.

A surprise finding of the study was that physicians who reported more training in IUD use and insertion were more likely to opt for removal of the IUD.

"This was an unexpected result. You would expect physicians with previous training to be more familiar with the guidelines and allow these patients to be managed conservatively," said Dr. Cottongim.

She said the survey did not collect data on the year of a physician's training, the type of training, or whether they were currently inserting IUDs as part of their clinical practice.

All of the women were in situations where we would have chosen not to remove their long-term birth control.

"If IUD training was remote to collection of the survey, they may not have been up to date with current guidelines," she said. "Additionally, if they were not inserting IUDs as part of their clinical practice, they may not have perceived a need to stay up to date with information. And certainly if they received training in a less formal situation, they may not have interpreted that they actually received training and may have selected a different answer."

The study's findings underscore the obligation of clinicians to stay informed and trained, said Dr. Cansino.

"We have the obligation to provide excellent care, and part of that responsibility revolves around continuing to educate ourselves," she said. "If women choose to use an IUD...then physicians must support that intention and allow them to keep the IUD — especially when the guidelines support this practice."

"This study shows that as IUD use increases in the United States, education on management over time needs to include primary care providers," said Stephanie Teal, MD, from the University of Colorado Denver School of Medicine, who was asked by Medscape Medical News to comment on the findings.

The question remains whether primary care providers are actually interested in learning how to manage IUD complications or questions, she noted.

"Updating practicing physicians is an ongoing problem," said Dr. Teal. "Some will prefer just to refer to the gynecologist, but in the emergency room situation, women may not have that option. There is also the issue of people not knowing what they don't know, and not considering calling an expert because they think they know the correct, old-fashioned, way of managing."

Dr. Cottongim reports that she owns stock with Merck and Company, Inc. Dr. Cansino, the other study authors, and Dr. Teal have disclosed no relevant financial relationships.

American Congress of Obstetricians and Gynecologists (ACOG) 61st Annual Clinical Meeting: Abstract SY07. Presented May 7, 2013.

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